INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on July 27 & 28, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Gaudenzia, Inc., west Chester were substantiated. A plan of correction must be submitted by 12/23/10.
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Plan of Correction
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704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
Based interviews with clients, a physical plant tour, a review of the facility's incident log, a review of one personnel record, a discussion with the facility's program director,and the findings of the complaint investigation, the facility failed to employ sufficient support staff.
The findings include:
On July 27, 2010 two staff from the Division of Drug and Alcohol Program Licensure conducted a complaint investigation surrounding inappropriate sexual conduct and misuse of authority by a staff member of the facility.
A review of the personnel record confirmed that the evening/night supervisor did engage in a misuse of authority and engaged in inappropriate conduct with a client.
Clients confirmed that the supervisor had been having a sexual relationship with one or more clients, and due to limited staff on the second and third shifts, it was easy for this to occur.
The physical plant conditions of the building resulted in five citations. See 705.(2), 705.6(6), 705.6(7) and 705.9(1) further confirming the need for additional support staff.
The facility program director confirmed that one employee had engaged in inappropriate conduct relating to a client and the staff person was terminated from employment. The facility program director also confirmed the physical plant conditions.
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Plan of Correction
Beginning in the interview process, all managers have been trained to stress the importance of appropriate boundaries and ethical practices with potential employees. As a follow-up to that practice, the Program Director/Division Director reiterates the importance of appropriate boundary setting/ethical practices in the second interview before it is confirmed that individuals are eligible and/or viable candidates for employment.
Furthermore, on the 8th of December, Program Director, Drug and Alcohol Division Director, and Eastern Region Director met to discuss the current status and roster of GHWC. During that meeting, Program Director discussed the need to revise the present roster by adding another slot for a Counselor, 1 Full-Time House Manager, or 2 Part-Time House Managers.
Finally, another planning meeting was scheduled, but due to ongoing inclement weather it has been postponed until the beginning of February. It is still hoped that the agenda for this meeting will be to further discuss the issue of making the abovementioned revisions to the roster to increase staff coverage/demand. Also, Program Director will elicit suggestions from Division and Regional Directors to see about ways to include screening questions into the reference checks in an attempt to further decrease hiring of staff with inappropriate boundaries.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on interviews with four clients on July 27, 2010, a number of physical plant concerns were identified. Based on observation during the physical plant inspection that was conducted on July 27, 2010, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of the residents, employees and visitors.
The findings include:
Four clients were interviewed on July 27, 2010. Client #1 advised there were issues with mold in the basement carpets and no soap in the bathrooms.
Client #4 advised the inspectors that there was mildew in the basement, moldy shower curtains in the bathrooms, and a dripping sink in the kitchen.
Complaints made concerning the physical plant during these interviews led the Licensing Specialists to conduct a physical plant inspection. A physical plant inspection was conducted on July 27, 2010 from approximately 1:30 PM to 3:30 PM. The facility's regional director accompanied the Licensing Specialists on this physical plant inspection.
The walls in the weight room, which is located in the basement, were damp to the touch. Two holes were located in the wall. The paint was peeling and the drywall was crumbling. A ceiling tile in the basement had a patch of black mold on it. The paint on the window frame in the basement was peeling and the frame itself was rusted.
The dishwasher in the kitchen on the first floor was leaking and causing a large puddle of water to collect in the middle of the floor where people were walking back and forth.
A closet in the female dorm on the first floor that was labeled by the facility as a "caustic closet" had an overhead light dangling from the ceiling by it's electrical wiring.
A ceiling tile was falling down/out in room #5 over the bed labeled by the facility as #19 in the female dorm on the first floor. Several ceiling tiles over the bed labeled by the facility as #12 in room #8 of the men's dorm on the second floor were bowed/warped. Several ceiling tiles in room #1 on the second floor men's dorm were missing.
The plastic covers over the fluorescent lighting were cracked/broken in room #12 on the second floor men's dorm. The plastic covers over the fluorescent lighting were missing in room #8 on the second floor men's dorm and in the "Philly Dorm" on the second floor above the bed labeled by the facility as #18.
The carpet on the second floor in the dorm labeled as the "Philly Dorm" had a scorch mark in the shape of an iron.
A portable box fan was hanging from the ceiling by a t-shirt that was tied around it and the metal brace that holds the ceiling tiles in place.
There was a hole in the wall in room #2 on the female dorm on the first floor and behind the door in room #3 on the male dorm on the second floor.
The curtain rod behind bunk beds labeled by the facility as #15 and #16 was bent, bowed out and falling down.
The blinds in room #2 on the male dorm on the second floor were ripped off the window and leaning against the wall in the closet. One half of the window pane in this room was also removed and leaning against the wall in the closet.
The facility's regional director confirmed the findings.
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Plan of Correction
Presently, 75% of the identified physical plant issues noted in the observations have been fixed. However, all identified physical plant issues were inputted into the agency wide maintenance system at the time of the inspection.
Furthermore, the remaining physical plant issues will be inputted into the maintenance system again and the will be communicated to the Director of Maintenance.
Outside of the physical plant issues that cannot be handled without the assistance of the Property Managers, GHWC has delegated Program Supervisor and a House Manager to visually inspect and notate all physical plant issues on a weekly basis. Depending on the severity of the issue, House Manager and/or Program Supervisor will ensure the issue is rectified and/or given to the appropriate parties via implementation into the maintenance system.
Program Supervisor will also communicate all physical plant issues, address and/or unaddressed in weekly management meetings to ensure adequate follow through and follow up.
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705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on interviews with clients on July 27, 2010, a number of physical plant concerns were identified. Based on observation during the physical plant inspection that was conducted on July 27, 2010, the facility failed to provide toilet paper at each toilet at all times.
The findings include:
Four clients were interviewed on July 27, 2010.
Complaints made concerning the physical plant during these interviews led the Licensing Specialists to conduct a physical plant inspection. A physical plant inspection was conducted on July 27, 2010 from approximately 1:30 PM to 3:30 PM. The facility's regional director accompanied the Licensing Specialists on this physical plant inspection.
Both toilet stalls in Bathroom A on the second floor in the men's wing were missing toilet paper. There was no toilet paper supplied in this bathroom during the physical plant inspection.
The facility's regional director confirmed the findings.
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Plan of Correction
Since the site visit, GHWC has hired a Program Supervisor and a House Manager to oversee the quantity and order of supplies.
Supplies House Manager will monitor household supplies, which include toilet paper, and order the needed/necessary quantities on a biweekly basis.
In addition to acquiring this House Manager to oversee this aspect of the program, all House Managers and clients in the facility have and continue to be taught/trained on completing multiple checks of the facility, which includes the restrooms, to ensure adequate supplies are present at all times. If area were to be found to be missing an essential item, request for these supplies will be noted and given to the proper party to ensure adequate follow through and follow up.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on interviews with clients on July 27, 2010, a number of physical plant concerns were identified. Based on observation during the physical plant inspection that was conducted on July 27, 2010, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The findings include:
Four clients were interviewed on July 27, 2010.
Client #1 advised there was no soap in the bathrooms.
Client #4 advised the inspectors that there were moldy shower curtains in the bathrooms.
Complaints made concerning the physical plant during these interviews led the Licensing Specialists to conduct a physical plant inspection. A physical plant inspection was conducted on July 27, 2010 from approximately 1:30 PM to 3:30 PM. The facility's regional director accompanied the Licensing Specialists on this physical plant inspection.
The shower tiles in the women's wing on the first floor were black with mold. The men's bathroom labeled C on the second floor had a tile missing near the light switch with a large amount of grout exposed and a cracked light cover for the florescent lighting. The men's bathroom labeled A on the second floor had a large shower curtain tied up and lying on the floor in the shower. This shower curtain was filled with some form of unidentifiable liquid. Soap in this bathroom was not provided in the soap dispensers, rather the plastic refill bag was lying on the counter.
The facility's regional director confirmed the findings.
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Plan of Correction
Program Director, Program Supervisor, and Clinical Supervisor have implemented a schedule for all staff and clients to designate scheduled times throughout the day in which areas of the program, which include the bathrooms, are checked.
All facility staff and clients in the facility have and continue to be taught/trained on completing multiple checks of the facility, which includes the restrooms, to ensure cleanliness at all times. If area were to be found to be in need of cleaning, a request for this cleaning will be noted and given to the proper party to ensure adequate follow through and follow up.
In addition to the outstanding maintenance issues, orders have been submitted to the Property Manager and the will be corrected.
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705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on interviews with clients on July 27, 2010, a number of physical plant concerns were identified. Based on observation during the physical plant inspection that was conducted on July 27, 2010, the facility failed to be free of rodent and insect infestation.
The findings include:
Four clients were interviewed on July 27, 2010. Complaints made concerning the physical plant during these interviews led the Licensing Specialists to conduct a physical plant inspection. A physical plant inspection was conducted on July 27, 2010 from approximately 1:30 PM to 3:30 PM. The facility's regional director accompanied the Licensing Specialists on this physical plant inspection.
The floor of the bathroom beside the physician's office on the first floor was littered with dead insects and had a live insect crawling on it.
The staircase leading down to the weight room in the basement was littered with dead insects and spider webs.
The bathroom on the third floor was littered with dead insects on July 27, 2010 during the physical plant inspection and on July 28, 2010 while in use by the Licensing Specialist.
The facility's regional director confirmed the findings.
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Plan of Correction
Since the site visit, Erlich, a contracted exterminator, has been out to the facility to inspect and exterminate the stink bugs that have been found and/or noted in the observations. Furthermore, this contractor visits the facility on a monthly basis to regularly exterminate.
Program Director, Program Supervisor, and Clinical Supervisor have implemented a schedule for all staff and clients to designate scheduled times throughout the day in which areas of the program are checked.
All facility staff and clients in the facility have and continue to be taught/trained on completing multiple checks of the facility to ensure cleanliness at all times and that areas are free of rodents. If area were to be found to be in need of cleaning, a request for this cleaning will be noted and given to the proper party to ensure adequate follow through and follow up.
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705.9 (5) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(5) Notify the Department within 48 hours of a fire, other disaster or situation which affects the continuation of services.
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Observations
Based on interviews with clients, a review of the facility's incident log, communication log and a discussion with the facility's program director, the facility failed to notify the Department within 48 hours of a fire.
The findings include:
On July 27, 2010, four clients were individually interviewed. When the clients were asked if they had any safety concerns while at the facility, each client, clients #1, 2, 3, and 4 stated they did not feel safe and referenced a fire that had been set by another client within one week of the visit. The Licensing Specialists were informed by the clients that there had been a fire within the facility on July 22, 2010. This information was confirmed when speaking with the facility's program director. During a review of the facility's incident report log, the Licensing Specialists found an incident report that had been prepared by the facility concerning the fire. This incident report was dated July 22, 2010. The facility did not inform the Department of this incident.
A review of the communication log confirmed the fire, indicated an interruption of services from 12:40 PM - 1:45 PM and included the following statements:
12:40 PM- Alarm Sounded- All clients evacuated safely. Client went to his room to check on his items, smoke was coming from that room. He came back down safely. Room 2 is the room in question.
12:50 PM- Police arrive
12:55 PM- Fire Dept arrives
1:10 PM - Clients and staff are not allowed to go back into the main building yet. Fire Dept still investigating incident. Clients and Staff move into Nelson Center until cleared to go into WCH. Population called at 1:15 PM in the Nelson Center.
1:45 PM - Family cleared to go back into WCH. All clients from room #1 are being confronted and talked to about their whereabouts and conditions of their items.
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Plan of Correction
GHWC staff will notify the Department of Health within 48 hours of a fire, other disaster or situation which affects the continuation of services.
Program Director will ensure that Incident Report is sent to Department of Health within the appropriate timeframe.
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